Admission triage tool for adult intensive care unit admission in Hong Kong during the COVID-19 outbreak.

Intensive care is expensive, and the numbers of intensive care unit (ICU) beds and trained specialist medical staff able to provide services in Hong Kong are limited. The most recent increase in coronavirus disease 2019 (COVID-19) infections over July to August 2020 resulted in more than 100 new cases per day for a prolonged period. The increased numbers of critically ill patients requiring ICU admission posed a capacity challenge to ICUs across the territory, and it may be reasonably anticipated that should a substantially larger outbreak occur, ICU services will be overwhelmed. Therefore, a transparent and fair prioritisation process for decisions regarding patient ICU admission is urgently required. This triage tool is built on the foundation of the existing guidelines and framework for admission, discharge, and triage that inform routine clinical practice in Hospital Authority ICUs, with the aim of achieving the greatest benefit for the greatest number of patients from the available ICU resources. This COVID-19 Crisis Triage Tool is expected to provide structured guidance to frontline doctors on how to make triage decisions should ICU resources become overwhelmed by patients requiring ICU care, particularly during the current COVID-19 pandemic. The triage tool takes the form of a detailed decision aid algorithm based on a combination of established prognostic scores, and it should increase objectivity and transparency in triage decision making and enhance decision-making consistency between doctors within and across ICUs in Hong Kong. However, it remains an aid rather than a complete substitute for the carefully considered judgement of an experienced intensive care clinician.

A dominant strain of Elizabethkingia anophelis emerged from a hospital water system to cause a three-year outbreak in a respiratory care center.

BACKGROUND: Elizabethkingia species are ubiquitous bacteria but uncommonly cause human infection. An outbreak of Elizabethkingia anophelis bacteraemia was observed in a respiratory care center of a tertiary hospital in Taiwan from 2015 to 2018. METHODS: Clinical and environmental isolates were collected for the outbreak investigation. Pulsed-field gel electrophoresis (PFGE) and complete-genome sequencing were conducted to elucidate the mechanism of transmission. FINDINGS: The three-year outbreak involved 26 patients with E. anophelis bacteraemia and the incidence significantly increased during the outbreak period compared with that observed from 2010 to 2014 (P<0.05). All 26 clinical isolates during the outbreak period belonged to a cluster by PFGE analysis. In contrast, the PFGE pattern was heterogeneous among comparative historical strains. Hospital tap water was highly contaminated by Elizabethkingia species (18/34, 52.9%); among that, five E. anophelis belonged to the outbreak cluster (5/18, 27.8%). As for the inanimate surface survey, 3.4% sites (4/117) revealed positive growth of E. anophelis including two from feeding tubes/bags and two from sputum suction regulators. All four isolates belonged to the outbreak clone. The outbreak strain had no apparent relationship to currently known E. anophelis strains worldwide through complete-genome sequencing analysis. Specific infection control strategies aimed at water source control and environmental disinfection were implemented subsequently and the outbreak ended in mid-2018. CONCLUSIONS: A specific E. anophelis strain was identified from a three-year outbreak. The elucidation of the mechanism of dominance and intra-hospital transmission is crucial for development of corresponsive infection control policies and outbreak control.

Pneumatosis cystoides intestinalis: Not uncommon cause of free air in acute abdomen.

Pneumatosis cystoides intestinalis is generally benign in course and sometimes, if cysts ruptured, behave as the not uncommon cause of free air in acute abdomen. In our case, we illustrate ruptured isolated cysts of pneumatosis cystoides intestinalis are responsible for pneumoperitoneum in a 94-year-old male patient. Laparotomy with gastrotomy for decompression of intraluminal aeropressure was performed, with an uneventful recovery. This paper presents with preoperative and intraoperative images of high educational value for this, often underdiagnosed, clinical entity.

Genitourinary syndrome of menopause in five Asian countries: results from the Pan-Asian REVIVE survey.

OBJECTIVES: The Pan-Asian REVIVE survey aimed to examine women's experiences with genitourinary syndrome of menopause (GSM) and their interactions with health-care professionals (HCPs). METHODS: Self-completed surveys were administered face-to-face to 5992 women (aged 45-75 years) in Indonesia, Malaysia, Singapore, Taiwan, and Thailand. RESULTS: Of 638 postmenopausal women with GSM symptoms, only 35% were aware of the GSM condition, most of whom first heard of GSM through their physician (32%). The most common symptoms were vaginal dryness (57%) and irritation (43%). GSM had the greatest impact on sexual enjoyment (65%) and intimacy (61%). Only 25% had discussed their GSM symptoms with a HCP, and such discussions were mostly patient-initiated (64%) rather than HCP-initiated (24%). Only 21% had been clinically diagnosed with GSM and only 24% had ever used treatment for their symptoms. Three-quarters of those who had used treatment for GSM had discussed their symptoms with a HCP compared to only 9% of those who were treatment-naïve. CONCLUSION: GSM is underdiagnosed and undertreated in Asia. As discussion of GSM with HCPs appears to be a factor influencing women's awareness and treatment status, a more active role by HCPs to facilitate early discussions on GSM and its treatment options is needed.

Selection of GP. Mur antigen-negative RBC for blood recipients with anti-'Mia ' records decreases transfusion reaction rates in Taiwan.

OBJECTIVES: To evaluate the clinical significance of GP. Mur antigen-negative blood selection for transfusion in patients with anti-'Mia ' records. BACKGROUND: The GP. Mur RBC phenotype is prevalent (7·3%) in Taiwan. Antibodies against GP. Mur (anti-'Mia ') are identified in 1·24% of our population, and anti-'Mia ' screening using GP. Mur RBC has been routine for Taiwan's blood banks. However, due to the lack of commercial antibodies, only cross-matching was used to prevent transfusion of GP. Mur-positive blood to patients with anti-'Mia ' in most hospitals. There is still a risk of GP. Mur-positive RBC exposure and subsequent anti-'Mia '-related transfusion reactions. METHODS: Since February 2014, GP. Mur antigen-negative RBCs identified by reaction with anti-'Mia '-positive serum were selected for blood recipients with anti-'Mia ' records. The transfusion reactions between January 2013 and January 2014 were compared with those that occurred between February 2014 and July 2015. RESULTS: The transfusion reaction rate was significantly higher in anti-'Mia '-positive blood recipients compared to total subjects receiving an RBC transfusion before GP. Mur-negative donor RBC selection. After antigen-negative RBC selection, the transfusion reaction frequency in subjects with anti-'Mia ' became similar to total blood recipients. IgG form anti-'Mia ' antibodies were present in all cases of probable anti-'Mia '-related transfusion reactions. The time required for anti-'Mia ' boosting after transfusion was around 4-21 days. CONCLUSION: Selection of GP. Mur-negative RBC for transfusion to patients with anti-'Mia ' records could decrease the rate of transfusion reaction and antibody boosting. This procedure should be incorporated into blood bank routines in areas where anti-'Mia ' is prevalent.

Development of anti-influenza A compounds: a pilot study.

1. There is no effective anti-H5N1 avian influenza agent. 2. A chemical compound­ BFDBSC­can inhibit H5N1 virus infection in cell cultures, and such inhibition might be attributable to its halogenated benzoyl residues. 3. This pilot study assessed anti- H5N1 activity and toxicity of four chemical compounds with halogenated benzoyl residues in cell culture system. 4. Two compounds­FPBFDBSC and BFB-gallate­ showed higher antiviral effectsthan BFDBSC, whearas the other two­BFB-borneol and BFB-menthol­showed lower antiviral effects. These compounds did not show toxicity. 5. The halogenated benzoyl residues may play a key role in anti-H5N1 effects. However, all these compounds showed poor solubility, which may limit their utility

Immune responses to tyrophagus putrescentiae-induced airway inflammation in mice.

BACKGROUND: Storage mites are a source of aeroallergens that affect patients with allergic rhinitis and asthma. Tyrophagus putrescentiae is a causative factor of airway hypersensitivity, but the mechanisms and pathogenesis of Tputrescentiae-induced allergy are not well understood. OBJECTIVE: This study aimed to develop a murine model of T putrescentiae-induced allergic asthma. METHODS: Immune responses and physiologic variations in immunoglobulins (Ig), leukocyte subpopulations, cytokines, gene expression, pulmonary function, and lung pathology were evaluated after intraperitoneal sensitization and intratracheal challenge with crude extract of T putrescentiae. RESULTS: After sensitization with aluminum hydroxide and challenge with T putrescentiae in mice, levels of T putrescentiae-specific IgE and IgG1 in sera increased significantly compared to the normal saline group (P < .01): Values for inflammatory leukocytes (neutrophils and eosinophils) and cytokines (interleukin [IL] 4, IL-5, and IL-13) increased significantly after sensitization. In terms of pulmonary function, pause values were significantly enhanced in T putrescentiae-sensitized mice after intratracheal challenge with T putrescentiae (P < .05). Expression of type 2 helper T cell (T(H)2)-related genes (IL4, IL5, IL13, and RANTES), T(H)2-specific transcription factor (GATA-3), and proinflammatory genes (IL6), and T(H)(H)17-related genes (IL17F) increased significantly after airway challenge. Sensitization with T putrescentiae crude extract led to inflammation of lung tissue, thickening of the tracheal wall, and tracheal rupture. CONCLUSIONS: Intraperitoneal sensitization followed by intratracheal challenge with crude extract of T putrescentiae can induce airway inflammation in BALB/c mice. The symptoms observed in a mouse model of allergic asthma, in terms of immune and clinical parameters, are reminiscent of the symptoms of allergic asthma in humans. A mouse model can be used to evaluate the therapeutic effectiveness of drugs on T putrescentiae-induced airway inflammation in humans.

Impact of lymphadenectomy in uterine endometrioid carcinoma.

AIMS: To investigate the role of lymphadenectomy in uterine endometrioid carcinoma based on the 2009 FIGO staging system. METHODS: Using an institution-maintained cancer registry database, all patients who were treated surgically for endometrial cancer from 1991 to 2008 in two medical centers were analyzed. Kaplan-Meier and Cox proportional hazards methods were used to determine the role of lymphadenectomy. RESULTS: From 961 women with uterine endometrioid carcinoma, 680 underwent lymphadenectomy and 281 did not. Young age, early-stage disease, low-grade tumor, and lymphadenectomy were favorable independent prognostic factors. The five-year disease-specific survival (DSS) of stages IA, IB, II, and III, and the two-year DSS of stage IV patients who underwent lymphadenectomy were 97.8%, 88.3%, 91.5%, 70.5%, and 32.1%, respectively, compared to 98.7%, 70.0%, 73.3%, 42.9%, and 16.6% in those without lymphadenectomy (p > 0.05 for stage IA; p < 0.01 for stages IB-IV, log-rank test). In high-risk patients (i.e., poorly-differentiated, outer-half myometrial invasion, and stages II-IV), more extensive lymph node resection was associated with an improved five-year DSS, from 71.3% (1-10 nodes removed) and 85.3% (11-20 nodes removed) to 86.8% (>20 nodes removed) (p = 0.02, log-rank test). For stage IIIC-IV patients with nodal metastasis, the extent of node resection also significantly improved the five-year DSS, from 34.4% (1-10 nodes removed) and 62.4% (11-20 nodes removed) to 79.6% (>20 nodes removed) (p = 0.04, log-rank test). CONCLUSIONS: Lymphadenectomy improves the survival of patients with uterine endometrioid carcinoma stage IB to stage IV. The extent of lymphadenectomy also improves the survival of high-risk patients and those with nodal disease.

Immune Responses to Tyrophagus putrescentiae–Induced Airway Inflammation in Mice

Antecedentes: Los ácaros de almacenamiento son una fuente de aeroalérgenos en pacientes con rinitis y asma alérgica. El Tyrophagus putrescentiae (Tp) es causante de reacciones de hipersensibilidad de las vías respiratorias, sin embargo los mecanismos y la patogenia de esta enfermedad están aún por dilucidar. Objetivo: El presente estudio tuvo como objetivo el establecer un modelo murino de asma alérgica inducida por el Tp. Métodos: Los ratones fueron sensibilizados con un extracto crudo de Tp por vía intra-peritoneal y, posteriormente, provocados con el mismo, por vía intratraqueal. Se cuantificaron diferentes parámetros de la respuesta inmunitaria como: variaciones en la concentración de inmunoglobulinas, subpoblaciones leucocitarias, citocinas y expresión de genes, así como la función pulmonar y, finalmente, se realizaron estudios histológicos. Resultados: Los ratones sensibilizados y provocados con Tp desarrollaron un aumento significativo de los niveles de IgE e IgG1 específicas de Tp en suero, en comparación con el grupo NS (p <0,01). Asimismo, se observó un incremento significativo, después de la sensibilización, en la cifra de leucocitos inflamatorios (neutrófilos y eosinófilos) y de algunas citocinas (IL-4, IL-5 e IL-13). En la función pulmonar, se obtuvieron valores significativamente mayores de Penh (p <0,05) en los ratones sensibilizados a Tp. En el estudio de la expresión génica, se observó que los genes relacionados con la respuesta Th2 (IL-4, IL-5, IL-13, y RANTES), Th2 específica del factor de transcripción GATA-3, pro-inflamatoria (IL-6), y Th17 (IL-17F), aumentó significativamente tras la provocación intratraqueal. En los ratones sensibilizados con extracto crudo Tp se confirmó una histología pulmonar con inflamación del tejido pulmonar y alteraciones traqueales. Conclusión: La sensibilización intraperitoneal con extracto crudo de T. putrescentiae, seguida de una provocación intratraqueal, puede inducir la inflamación de las vías aéreas en ratones. Este modelo murino pudiera servir de base para evaluar la eficacia terapéutica de fármacos en la inflamación de las vías respiratorias, inducida por T. putrescentiae, dadas las similitudes encontradas en aspectos inmunológicos y clínicos, con el asma alérgica de los seres humanos (AU)

Background: Storage mites are a source of aeroallergens that affect patients with allergic rhinitis and asthma. Tyrophagus putrescentiae is a causative factor of airway hypersensitivity, but the mechanisms and pathogenesis of T putrescentiae–induced allergy are not well understood. Objective: This study aimed to develop a murine model of T putrescentiae–induced allergic asthma. Methods: Immune responses and physiologic variations in immunoglobulins (Ig), leukocyte subpopulations, cytokines, gene expression, pulmonary function, and lung pathology were evaluated after intraperitoneal sensitization and intratracheal challenge with crude extract of T putrescentiae. Results: After sensitization with aluminum hydroxide and challenge with T putrescentiae in mice, levels of T putrescentiae–specific IgE and IgG1 in sera increased significantly compared to the normal saline group (P<.01). Values for inflammatory leukocytes (neutrophils and eosinophils) and cytokines (interleukin [IL] 4, IL-5, and IL-13) increased significantly after sensitization. In terms of pulmonary function, pause values were significantly enhanced in T putrescentiae–sensitized mice after intratracheal challenge with T putrescentiae (P<.05). Expression of type 2 helper T cell (TH2)–related genes (IL4, IL5, IL13, and RANTES), TH2-specifi c transcription factor (GATA-3), and proinflammatory genes (IL6), and TH17-related genes (IL17F) increased significantly after airway challenge. Sensitization with T putrescentiae crude extract led to inflammation of lung tissue, thickening of the tracheal wall, and tracheal rupture. Conclusions: Intraperitoneal sensitization followed by intratracheal challenge with crude extract of T putrescentiae can induce airway inflammation in BALB/c mice. The symptoms observed in a mouse model of allergic asthma, in terms of immune and clinical parameters, are reminiscent of the symptoms of allergic asthma in humans. A mouse model can be used to evaluate the therapeutic effectiveness of drugs on T putrescentiae–induced airway inflammation in humans (AU)

Anaerobic ammonium oxidation improvement via a novel capsule bioreactor.

This study developed a capsule bioreactor made from polyvinyl alcohol (PVA) to entrap anaerobic ammonium oxidation (ANAMMOX) bacteria for the removal of nitrogen from synthetic wastewater. Experimental results demonstrate that the ANAMMOX bacteria were entrapped inside the capsule and not washed out from the bioreactor. This method also avoids damaging the ANAMMOX bacteria during immobilization. The proposed bioreactor also has a shorter start-up period. The diffusion rate of ammonium and nitrite from the bulk solution through the capsule determined the rate of the ANAMMOX reaction. The optimal ratio of NO2(-)-N/NH4(+)-N was approximately 1 for the bioreactor. In addition, the capsule protected the ANAMMOX bacteria from nitrite inhibition. The bioreactor achieved a high stable nitrogen removal rate (5.8 Kg-N m(-3) day(-1)) at high nitrite levels (up to 600mg-N L(-1) in the influent). Therefore, the proposed capsule bioreactor has considerable potential for actual nitrogen removal applications.

Somatic LMCD1 mutations promoted cell migration and tumor metastasis in hepatocellular carcinoma.

Common genetic alteration in cancer genomes is implicated for embracing an aberrant cancer gene participated in tumor progression. In this study, we identified a somatic mutated LIM and cysteine-rich domains-1 (LMCD1) as a putative metastatic oncogene in human hepatocellular carcinoma (HCC) using integrated genomic approaches. In addition to revealing genomic amplification and gene upregulation, we identified recurrent E135K (3/48 cases) mutations in HCC tissues and K237R mutation in the PLC/PRF/5 HCC cell line. Expression of mutant LMCD1 E135K or K237R reduced the stress fiber assembly, increased cortical actin accumulation and induced lamellipodial extension. Consistently, these mutations enhanced cell migration and showed activation of the Rac1-signaling pathway. Inhibition of the LMCD1/Rac1 pathway by an LMCD1 short-hairpin RNA (shLMCD1) or the Rac1 inhibitor NSC23766 suppressed the mutation-mediated lamellipodial protrusion and cell migration. In PLC/PRF/5 cells with endogenous K237R mutation, cell migration was enhanced by estrogen-induced LMCD1 expression but reversed by shLMCD1 treatment. Moreover, overexpression of LMCD1 E135K mutation significantly promoted systemic lung metastasis in a murine tail vein injection model. Together, our results suggest that LMCD1 mutations are potential oncogenic events in HCC metastasis to promote cell migration through the Rac1-signaling pathway.

Clonal spreading of methicillin-resistant SCCmec Staphylococcus aureus with specific spa and dru types in central Taiwan.

The goal of this study was to delineate the molecular characteristics of methicillin-resistant Staphylococcus aureus (MRSA) in Taiwan. Ninety-six MRSA isolates were collected from the blood cultures of different patients during the period July to December of 2008. The spa typing, staphylococcal chromosomal cassette (SCCmec) typing, mec-associated direct repeat unit (dru) copy numbers, and toxin genes (sea, seb, sec, tst, lukS/F) of each isolate were determined. Thirty-eight, 28, 18, and 12 MRSA isolates were SCCmec type II, SCCmec type III, SCCmec type IV, and SCCmec type V, respectively. Most (31/38, 81.6%) of the SCCmec type II isolates were of spa t002 with four dru repeats. Some of them also carried the sec or tst toxin gene (67.7 and 80.6%, respectively). Of the 28 SCCmec type III MRSA isolates, 15 (53.6%) were of t037 with 14 dru repeats, and all also carried the sea gene. Of the 18 SCCmec type IV MRSA isolates, 13 (72.2%) were of t437 with nine dru repeats, and ten of them also had the seb gene. Among the SCCmec type V MRSA isolates, nine were type V(T). Five (55.6%) of them were of t437 with 11 dru repeats, and all contained the lukS/F gene. The clonal spreading of SCCmec MRSA strains with specific spa and dru types was found. Further longitudinal, multiple-site surveillance is required in order to define the MRSA evolution in Taiwan.

Clinical significance of signal pattern of high-risk human papillomavirus using a novel fluorescence in situ hybridization assay in cervical cytology.

The present study aimed to evaluate a novel fluorescence in situ hybridization (FISH) assay for detecting the high-risk human papillomavirus (HR-HPV) DNA and signal pattern in cervical cytology specimens and for identifying cervical intraepithelial neoplasia (CIN) lesions. One hundred and ninety-six liquid-based cytology specimens with CIN were recruited. The signal pattern (punctate, mixed punctate and diffuse, and diffuse) detected by FISH was compared with E6 mRNA and correlated with histological classification. FISH and E6-type specific polymerase chain reaction (PCR) had fair to good agreement for detecting HPV DNA across all grades of CIN (kappa coefficient, 0.37-0.73). Among 44 samples of negative FISH and positive E6 type-specific PCR in HPV 16, 18, 31, 33, 52 and 58, 82% (36/44) of E6 mRNA were not detected, in contrast to 41% (48/118) of positive FISH and positive E6 type-specific PCR (p <0.0001). Among HR-HPV DNA positive cases tested by the FISH assay, the specificity of predicting CIN3 using the punctuate pattern is higher than that using E6 mRNA (96.3% vs. 44.8%). The punctate pattern was 0% in patients with

In vitro study of biofilm formation and effectiveness of antimicrobial treatment on various dental material surfaces.

Elevated proportions of Candida albicans in biofilms formed on dentures are associated with stomatitis whereas Streptococcus mutans accumulation on restorative materials can cause secondary caries. Candida albicans, S. mutans, saliva-derived and C. albicans/saliva-derived mixed biofilms were grown on different materials including acrylic denture, porcelain, hydroxyapatite (HA), and polystyrene. The resulting biomass was analysed by three-dimensional image quantification and assessment of colony-forming units. The efficacy of biofilm treatment with a dissolved denture cleansing tablet (Polident(®)) was also evaluated by colony counting. Biofilms formed on HA exhibited the most striking differences in biomass accumulation: biofilms comprising salivary bacteria accrued the highest total biomass whereas C. albicans biofilm formation was greatly reduced on the HA surface compared with other materials, including the acrylic denture surface. These results substantiate clinical findings that acrylic dentures can comprise a reservoir for C. albicans, which renders patients more susceptible to C. albicans infections and stomatitis. Additionally, treatment efficacy of the same type of biofilms varied significantly depending on the surface. Although single-species biofilms formed on polystyrene surfaces exhibited the highest susceptibility to the treatment, the most surviving cells were recovered from HA surfaces for all types of biofilms tested. This study demonstrates that the nature of a surface influences biofilm characteristics including biomass accumulation and susceptibility to antimicrobial treatments. Such treatments should therefore be evaluated on the surfaces colonized by the target pathogen(s).

Prevalence and accessory gene regulator (agr) analysis of vancomycin-intermediate Staphylococcus aureus among methicillin-resistant isolates in Taiwan--SMART program, 2003.

The prevalence of methicillin-resistant Staphylococcus aureus (MRSA) in nosocomial staphylococcal infections in Taiwan has exceeded 50% since 2000. However, little relevant data has been available concerning vancomycin-intermediate S. aureus (VISA) and heteroresistant VISA (hVISA). We collected 1,000 MRSA isolates from ten medical center hospitals in Taiwan during 2003. All were initially screened for reduced susceptibility to vancomycin on brain heart infusion (BHI) agar containing 5 mg/L vancomycin. Among 34 MRSA isolates that grew on the screening plates, two VISA isolates (0.2%) and seven hVISA isolates (0.7%) were evident. Vancomycin-resistant S. aureus was not detected. The accessory gene regulator (agr) typing of all 1,000 MRSA strains were typed by multiplex polymerase chain reaction (PCR); 919 strains (91.9%) including the VISA and hVISA isolates belonged to agr group I, 78 strains (7.8%) were agr group II, two strains (0.2%) were agr group III, and one isolate (0.1%) was agr group IV. There was no relationship between sample sites and agr typing. In 2003, the incidence of hVISA and VISA in Taiwan was low. Continued surveillance is recommended, given the implementation of new Clinical and Laboratory Standards Institute (CLSI) criteria for S. aureus and the increasing clinical use of glycopeptides.

Epithelioid haemangioendothelioma of the anterior skull base: what is the optimal treatment?

We report an unusual malignant tumour affecting an unusual site. Epithelioid haemangioendothelioma was formerly considered a tumour of intermediate malignancy but has been reclassified as fully malignant. It is important to be aware of this clinical entity as the best hope of cure is timely radical resection. There is a paucity of evidence concerning the efficacy of alternative treatments because the tumour is very rare.